INTRODUCTION

A comprehensive Event Root Cause Analysis Procedure (ERCAP) was developed by ENCONET for the investigation and analysis of events involving equipment and human performance problems at complex industrial installations.

ERCAP presents a well structured approach for a systematic investigation and analysis of direct causes, contributing causes and root causes of operational events. The method has been demonstrated to be user-friendly and applicable to any operational event



BASIS OF THE ERCAP METHODOLOGY

The ERCAP approach is a blend containing elements of the Human Performance Investigation Process (HPIP) and the Management Oversight & Risk Tree (MORT), as well as other methods being used for identification of causes of events. By adapting the best elements of several approaches, ERCAP has proven to be applicable to a wide variety of events, and capable of focused identification of root causes regardless of their character (equipment, human factors or interfaces).

MAIN FEATURES OF THE ERCAP METHODOLOGY

Three basic elements are considered within ERCAP. Basic RCA techniques (i.e. Change Analysis, Barrier Analysis, Event & Causal Factor Charting and Tree Diagram) are refined to satisfy the purpose and the entire process of ERCAP. Elements of other advanced techniques, such as the Accident Evolution and Barrier (AEB) were incorporated to focus the interactions between human factors and technical systems. Some interesting features of ERCAP are:
An integrated process for systematic analyses, encompassing review of an event report and, step-by-step identification of direct, contributing and root causes;
A clever combination of refined RCA techniques to enable investigation and successive analysis of events;
An enhanced screening system using logic tree for identifying cause categories considering evolution at different stages and/or levels, from prevention measures to operator responses;
A comprehensive set of cause modules for identifying and allocating causal factors. Those include 7 cause categories and about 200 causal factors in tree structures;
Full report preparation and printing, including chronology causal factors depiction.

 
STEPS WITHIN ANALYSIS PROCESS

Within the ERCAP process several steps are taken for identification of casual factors and determination of root cause:

- Distinguishing non-event related factors;
- Applying the searches to identify other relevant factors;
- Highlighting underlying causal factors;
- Distinguishing causal factors not relevant for event;
- Determination of direct and contributing causes;

CUSTOMIZATION

ERCAP is not a rigid and prescriptive procedure, rather it provides an analytical process and tools for analysis of operational events. ERCAP is structured in two parts. Part I emphasizes the analytical process with steps, while Part II describes in detail the tools with examples. ERCAP could be adopted as a whole, in part, or be customized easily to meet specific needs. ENCONET offers full support with adaptation as well as training and implementation of ERCAP.

CERCA, COMPUTERISED EVENT ANALYSIS TOOL

The ERCAP is available as a PC-based event investigation and reporting procedure. The code package CERCA (Code for Event Root Cause Analysis) was developed by ENCONET to support the practical performance of RCA. CERCA provides a user-friendly interface for applying the flow charts and work sheets contained in ERCAP. Additionally, CERCA will be used to aid preparation for formal analyses, to streamline and document the RCA efforts, to generate the RCA reports and to maintain an interactive RCA database.